ALERT! Warning: your browser isn't supported. Please install a modern one, like Firefox, Opera, Safari, Chrome or the latest Internet Explorer. Thank you!
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Pneumonia (PN)

Release Notes:
Measure Information Form
Version 2015A


Pneumonia (PN)

Set Measures

Set Measure ID Measure Short Name
PN-3a Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
PN-6 Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP in Immunocompetent Patients)

General Data Elements

Element Name Collected For
Admission Date All Records,
Birthdate All Records,
CMS Certification Number Hospital Clinical Data File, Optional for All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Health Care Organization Identifier All Records, Aggregate Data File, Patient Population Data File, Hospital Clinical Data File,
Hispanic Ethnicity All Records,
ICD-9-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3
ICD-9-CM Other Procedure Codes All Records, Optional for All HBIPS Records
ICD-9-CM Other Procedure Dates All Records, Optional for All HBIPS and PBM Records
ICD-9-CM Principal Diagnosis Code All Records, Optional for HBIPS-2 and HBIPS-3
ICD-9-CM Principal Procedure Code All Records, Optional for All HBIPS Records
ICD-9-CM Principal Procedure Date All Records, Optional for All HBIPS and PBM Records
Payment Source All Records, Optional for HBIPS-2 and HBIPS-3
Race All Records,
Sex All Records,

Algorithm Output Data Elements

Element Name Collected For
Measure Category Assignment Calculation, Transmission, Hospital Clinical Data File
Measurement Value Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For
Arrival Date PN-3a,
Arrival Time PN-3a,
Blood Culture Collected PN-3a,
Chest X-Ray PN-3a,
Clinical Trial PN-3a,
Comfort Measures Only PN-3a,
ICU Admission or Transfer PN-3a,
Initial Blood Culture Collection Date PN-3a,
Initial Blood Culture Collection Time PN-3a,
Pneumonia Diagnosis: ED/Direct Admit PN-3a,
Transfer From Another Hospital or ASC PN-3a,


Related Materials

 Sorted ascending Document Name  
Acknowledgment and Conditions of Use  
Appendix A - ICD-9-CM Code Tables  
Appendix C - Medication Tables  
Appendix D - Glossary of Terms  
Appendix E - Overview of Measure Information Form and Flowchart Formats  
Appendix G - Resources  
Appendix H - Miscellaneous Tables  
Appendix P - preview section of ICD-10 Code Tables  
Appendix P - preview section of ICD-10 Crosswalks of code tables  
b. Data Dictionary  
Cover Page for the Joint Commission Manual  
Introduction to the Manual  
Missing and Invalid Data  
Sampling  
Table of Contents  
Transmission Alpha Data Dictionary  
Transmission Data Processing Flow: Clinical  
Transmission Data Processing Flow: Population and Sampling  
Transmission of Data  
Using the The Joint Commission's National Measure Specifications Manual  



Pneumonia (PN) Initial Patient Population

The population of the PN measure set is identified using 5 data elements:
  • ICD-9-CM Principal Diagnosis Code
  • ICD-9-CM Other Diagnosis Codes
  • Admission Date
  • Birthdate
  • Discharge Date

Patients admitted to the hospital for inpatient acute care are included in the PN Initial Patient Population and are eligible to be sampled if they have:
  • An ICD-9-CM Principal Diagnosis Code for PN as defined in Appendix A, Table 3.1, NO ICD-9-CM Other Diagnosis Code of Cystic Fibrosis as defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days
    OR
  • An ICD-9-CM Principal Diagnosis Code of Septicemia or Respiratory Failure as defined in Appendix A, Table 3.2 and Table 3.3 accompanied by an ICD-9-CM Other Diagnosis Code of PN as defined in Appendix A, Table 3.1, NO ICD-9-CM Other Diagnosis Code of Cystic Fibrosis as defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.

Note: The Joint Commission requires all PN measures to be collected and submitted as an entire measure set. Measures are specified in the aligned Specifications Manual for National Hospital Inpatient Quality Measures as well as in the Specifications Manual for Joint Commission National Quality Core Measures. The initial population and sampling should be determined for all of a hospital’s cases for the entire set, not at the individual measure level, even though individual measures are defined within the different manuals.

PN_Initial_Patient_Pop.jpg v1


PN Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Hospitals that have five or fewer PN discharges (both Medicare and non-Medicare combined) in a quarter are not required to submit PN patient level data to the QIO Clinical Warehouse and Joint Commission’s Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling

Hospitals performing quarterly sampling for PN must ensure that its Initial Patient Population and sample size meet the following conditions:

Quarterly Sample Size
Based on Initial Patient Population for the PN Measure Set
Hospital's Measures
Average Quarterly
Initial Patient Population
Size "“N"”
Minimum Required
Sample Size
"“n"”
>= 1201 241
301 - 1200 20% of the Initial Patient Population
60 - 300 60
6 - 59 No sampling; 100% of the Initial Patient Population required
0 - 5 Submission of patient level data is encouraged but not required:
-CMS: if submission occurs, 1 – 5 cases of the Initial Patient Population may be submitted
-The Joint Commission: if submission occurs, 100% Initial Patient Population required

Monthly Sampling

Hospitals performing monthly sampling for PN must ensure that its Initial Patient Population and sample size meet the following conditions:

Monthly Sample Size
Based on Initial Patient Population for the PN Measure Set
Hospital's Measures
Average Monthly
Initial Patient Population
Size "“N"”
Minimum Required
Sample Size
"“n"”
>= 401 81
101 -– 400 20% of the Initial Patient Population
20 -– 100 20
< 20 No sampling; 100% of the Initial Patient Population required

Sample Size Examples

  • Quarterly sampling:
    • A hospital'’s Initial Patient Population size for the PN measure set is 171 PN discharges during the first quarter. The required quarterly sample is 60 cases.
    • A hospital'’s PN Initial Patient Population size is 1,199 patients during the third quarter. The calculated sample size is 20% of the patient population or 240 cases for the quarter (twenty percent of 1,199 equals 239.8 rounded to the next highest whole number equals 240).
    • A hospital'’s PN Initial Patient Population size is 3 patients during the second quarter. Submission of patient level data is not required. If the hospital chooses to submit patient level data:
      • CMS: the quarterly sample size would be 1 -– 3 cases for the quarter
      • The Joint Commission: the required quarterly sample size would be 100% of the patient population or 3 cases for the quarter.

  • Monthly sampling:
    • A hospital’'s Initial Patient Population size for the PN measure set is 800 PN discharges during January. Twenty percent of 800 equals 160 pneumonia patients -- which exceeds the maximum monthly sample size condition (i.e., 81); thus, the required sample size would be at least 81 pneumonia patients for that month.
    • A hospital'’s PN Initial Patient Population size is 399 patients during July. The required sample size is 20% of the patient population or 80 cases for the month (twenty percent of 399 equals 79.8 rounded to the next highest whole number equals 80).

Measure Information Form PN
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)

^